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Negotiating violence in the context of transphobia and criminalization : the experience of trans sex… Lyons, Tara; Krusi, Andrea; Pierre, Leslie; Kerr, Thomas; Small, Will; Shannon, Kate 2017

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Qualitative Health Research2017, Vol. 27(2) 182 –190© The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1049732315613311qhr.sagepub.comViolenceA growing body of international evidence suggests that sex workers face a disproportionate burden of violence compared with the general population, with significant variations occurring across social, legal, cultural, and economic contexts (Beattie et al., 2010; Deering et al., 2014; Kurtz, Surratt, Inciardi, & Kiley, 2004; Lowman, 2000). The majority of research has focused on women sex workers with a growing body of research on trans sex workers—those whose gender identity or expression dif-fers from their assigned birth sex—emerging in global settings (Bhattacharjya et al., 2015; Infante, Sosa-Rubi, & Cuadra, 2009; Rhodes, Simić, Baros, Platt, & Zikic, 2008; Socías, Marshall, Arístegui, Romero, et al., 2014). This research suggests that trans sex workers may be par-ticularly vulnerable to violence due to a complex inter-play of social-structural contexts. For example, Hwahng and Nuttbrock’s (2007) study of three trans communities demonstrated how social-structural contexts of racism and economic barriers shaped vulnerabilities to violence. In addition, within the epidemiological literature, trans women sex workers have been found to experience sig-nificantly higher rates of physical and sexual violence by clients than cisgender sex workers—individuals whose assigned sex corresponds to their gender identity and gender expression (Cohan et al., 2006; Johnson, 2013; Nemoto, Bodeker, & Iwamoto, 2011).Prior research has shown that many trans individuals face stigma (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Logie, James, Tharao, & Loutfy, 2012; Sevelius, 2013)—stigma which can con-tribute to violence (Lombardi, Wilchins, Priesing, & Malouf, 2001; Mogul, Ritchie, & Whitlock, 2011; Perry & Dyck, 2014). For example, youth who display gender nonconforming behaviors may face family rejection and end up experiencing violence in street-based 613311QHRXXX10.1177/1049732315613311Qualitative Health ResearchLyons et al.research-article20151University of British Columbia, Vancouver, British Columbia, Canada2Providing Alternatives, Counselling & Education (PACE) Society, Vancouver, British Columbia, Canada3Simon Fraser University, Burnaby, British Columbia, CanadaCorresponding Author:Kate Shannon, Associate Professor, Department of Medicine, and Director, Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, Canada V6Z 1Y6. Email: gshi@cfenet.ubc.caNegotiating Violence in the Context  of Transphobia and Criminalization:  The Experiences of Trans Sex Workers  in Vancouver, CanadaTara Lyons1, Andrea Krüsi1, Leslie Pierre2, Thomas Kerr1,  Will Small3, and Kate Shannon1AbstractA growing body of international evidence suggests that sex workers face a disproportionate burden of violence, with significant variations across social, cultural, and economic contexts. Research on trans sex workers has documented high incidents of violence; however, investigations into the relationships between violence and social-structural contexts are limited. Therefore, the objective of this study was to qualitatively examine how social-structural contexts shape trans sex workers’ experiences of violence. In-depth semistructured interviews were conducted with 33 trans sex workers in Vancouver, Canada, between June 2012 and May 2013. Three themes emerged that illustrated how social-structural contexts of transphobia and criminalization shaped violent experiences: (a) transphobic violence, (b) clients’ discovery of participants’ gender identity, and (c) negative police responses to experiences of violence. The findings demonstrate the need for shifts in sex work laws and culturally relevant antistigma programs and policies to address transphobia.Keywordssex work; violence; police; transgender; criminalization; structural violence; participatory analysis; qualitative; interviews; VancouverLyons et al. 183environments (Landolt, Bartholomew, Saffrey, Oram, & Perlman, 2004; Marksamer, 2008). Stigma, including barriers to health care and economic opportunities, greatly impacts the health of trans sex workers (Roche & Keith, 2014; Sausa, Keatley, & Operario, 2007). It has been suggested that sex work is one of a few viable economic opportunities for trans individuals (Poteat et al., 2015; Xavier et al., 2013), and a relationship has been found between barriers to economic security and violence among trans persons (Lombardi et al., 2001). Trans sex workers are also known to experience high rates of police-perpetuated violence in some settings (Rhodes et al., 2008), and the adverse impact of such violence on health care avoidance by trans sex workers has been observed (Socías, Marshall, Arístegui, Romero, et al., 2014). Therefore, social-structural con-texts shape trans persons’ experiences of violence and associated impacts on health.It is also understood that certain populations of trans sex workers face a range of stigma and barriers that heighten HIV vulnerabilities (Infante et al., 2009; Jürgens, Csete, Amon, Baral, & Beyrer, 2010; Poteat et al., 2015). Research has generally focused on trans women sex workers relationships and sexual practices (e.g., condom use) with clients and intimate partners. Often, however, the contexts in which relationships are situated remain overlooked despite knowledge that social-structural con-texts shape health and experiences of violence (Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Shannon et al., 2015).Social-structural contexts include the social, political, and legal contexts in which this study is situated. Our study takes place in the Downtown Eastside neighbor-hood of Vancouver, British Columbia, where, since the 1980s, more than 67 women, a third of whom were Indigenous and many of whom were involved in sex work, have been murdered or are missing (Amnesty International, 2009; Oppal, 2012). In addition, Canada’s sex work laws have recently undergone changes after legal challenges by sex workers. In December 2013, three sections of Canada’s prostitution laws, including commu-nicating in public for the purchase of prostitution, were ruled unconstitutional for violating sex workers’ rights (Sampson, 2014). In response, a year later the Canadian government implemented new prostitution legislation called the “Protection of Communities and Exploited Persons Act” that criminalizes the purchase of sex and the advertisement of sexual services for the first time in Canadian history, and continues to criminalize communi-cation in public for the purpose of prostitution (Government of Canada, 2014). This legislation has been criticized for its potential to contribute to even greater harm to sex workers (Krüsi et al., 2014; Sampson, 2014). Thus, this study is situated within a historic context of violence against sex workers and an evolving sex work legal framework.In summary, it has been documented that sex workers and trans persons are situated within social-structural contexts that can lead to health inequities and violence. While cisgender sex workers’ experiences in the study setting have been well documented, trans sex workers’ experiences of violence have been largely overlooked or combined with sexual minorities. Thus, the objective of this exploratory study was to investigate the lived experi-ences of violence and social-structural contexts shaping violence among trans sex workers in a Canadian setting.MethodStudy DesignThis study is situated within a qualitative and ethno-graphic examination of the physical, social, and policy factors that influence HIV prevention, treatment, and care for sex workers and people who use drugs, which includes longitudinal epidemiological cohorts of street and off-street sex workers (An Evaluation of Sex Workers Health Access) and people who use drugs (The At-Risk Youth Study, Vancouver Injection Drug Users Study, and AIDS Care Cohort to Evaluate Access to Survival Services). Cohort participants, who are recruited through commu-nity outreach and from research offices located in differ-ent neighborhoods of the city, complete structured questionnaires and clinical assessments biannually. The cohort methods have been described in detail elsewhere (Shannon et al., 2007; Strathdee et al., 1997; Tyndall et al., 2003; Wood, Stoltz, Montaner, & Kerr, 2006). Participants who identified as transgender, transsexual, genderqueer, or two-spirit1 in their baseline interviews (e.g., In the last 6 months, which of the following best describes your gender identity—check all that apply) were contacted via phone or email by Tara Lyons or front-line staff and invited to participate in the study. In addi-tion, three participants were referred to the study by other participants. Eligibility for this qualitative study included (a) having ever exchanged sex for money, (b) residing in the Greater Vancouver area, (c) being 14 years of age or older, and (d) identifying as persons whose gender iden-tity or expression differs from their assigned sex at birth.Between June 2012 and May 2013, Tara Lyons con-ducted 43 in-depth semistructured interviews with 33 trans sex workers. Follow-up interviews were conducted with 10 participants to expand on sex work–specific issues that arose during the first interviews, and more in-depth sex work questions were added to subsequent inter-views. Interviews were approximately 1 hour, and no participants declined to be interviewed or left the study after being interviewed. Interviews were audio recorded 184 Qualitative Health Research 27(2)with permission, and participants were paid CDN$20 to compensate for their time. All participants signed a writ-ten consent form that was reviewed verbally prior to the interview. This study holds ethical approval through Providence Health Care/University of British Columbia Research Ethics Board. Pseudonyms are used to protect the identity of participants.AnalysisInterview and ethnographic data were analyzed using a theory- and data-driven approach (DeCuir-Gunby, Marshall, & McCulloch, 2011) guided by a framework that positions health as an outcome of social-structural contexts (Rhodes et al., 2005; Shannon et al., 2008). Interviews were transcribed verbatim (excluding names) and imported into ATLAS.ti (Version 7) qualitative data analysis software to organize the data analysis. Tara Lyons conducted the first-level open coding. Additional data- and thematic-driven codes and subcodes were created dur-ing second- and third-level coding using a participatory analysis approach developed by Tara Lyons and two trans participants who were hired as researchers. Three partici-pants were invited to participate in the data analysis and one declined. Tara Lyons approached participants after their interview in-person or via email on the subjective basis of (a) power dynamics (e.g., comfort in challenging her ideas) and (b) engagement and interest during the interview. It was not possible to invite every participant to engage in the analysis due to financial and time con-straints. To further preserve confidentiality during the analysis process, any identifying information was removed from the text, and research assistants signed a confidenti-ality agreement.At each participatory analysis session, a hard copy of all the quotations associated with a first-level code (e.g., drug use) was printed and then split in half, with one half of the papers analyzed independently by each person. As a second step, the sections were exchanged for each sec-tion to be analyzed twice, once by Tara Lyons and once by a trans researcher. As a result, the data were analyzed 3 times. We validated the codes, corrected any errors, and discussed theoretical concepts, such as structural vio-lence, during the analysis sessions. New codes were also pulled from the analysis using an inductive approach (Thomas, 2006). For example, a research assistant devel-oped a “client shame” code during this level of coding to indicate how a client’s shame after sexual activity could lead to violence—a code that would have otherwise been missed. Codes were separated analytically into subcodes and were imported into the software, along with new codes and theoretical notes that were imported as memos, and reviewed during a subsequent analysis session. The 24 one-on-one analysis sessions ranged from 2 to 3 hours and were held at a research office. This approach was ini-tiated to ensure that data were not solely analyzed by Tara Lyons, a queer cisgender woman. Using a participatory analysis approach enriched and contextualized the research findings, and provided an opportunity to engage with research participants in the co-construction of knowledge (Fortin, Jackson, Maher, & Moravac, 2014; Shannon et al., 2007).ResultsParticipants ranged in age from 23 to 52 years, with an average age of 39 years. Twenty-three (69.7%) partici-pants identified as having Indigenous ancestry (inclusive of status or nonstatus First Nations and Métis2), seven (21.2%) identified as White, and three identified as Filipino, Asian, and “Other” visible minority, respec-tively. Approximately half of the sample (54.5% or n = 18) reported current use of illicit drugs, an additional five participants (15.2%) reported only cannabis use, and 10 (30.3%) reported no current drug use. The majority of participants (n = 26, 78.8%) were currently engaged in sex work and of those, 19 (73.1%) solicited in street sex work environments with the remainder soliciting clients online and/or working with regular clients in indoor envi-ronments. Among the 30 participants also enrolled in the cohort studies, 60% (n = 18) were living with HIV. Of the three individuals recruited from outside the cohort stud-ies, one self-reported living with HIV and two did not self-report their HIV status.GenderAll participants had been assigned male sex at birth; how-ever, they did not all identify as women and many used more than one category to describe their gender (e.g., transsexual and two-spirit). Participants most often described their gender as transgender (n = 16) and as women (n = 8). Seven participants identified as trans-sexual and six participants identified as two-spirit. Three participants reported dressing as a woman for sex work but had a masculine gender expression in other contexts. As one two-spirit individual explained, “When I was working . . . I’d dress up [as a woman] at night and then during the daytime I’d dress as a guy.” The final partici-pant identified as androgynous after living as a trans woman for many years. Thus, there was a range of gender identity and expression in the sample, and some partici-pants’ gender expression varied over time and with sex work.Our analyses revealed that violence was ubiquitous among trans sex workers in this setting and was shaped by the overlapping social-structural contexts of transpho-bia—the discrimination of and negative attitudes toward Lyons et al. 185individuals because of perceived gender identity and gen-der expression (Bettcher, 2007)—and criminalization of sex work. Three themes that emerged from the data are detailed below.Transphobic ViolenceParticipants described experiencing violence from clients because of their gender. As Kylie explained,[He] almost stabbed me . . . I seen that knife and I jumped out . . . He swung at me, but he never got me. I got out of the truck just in time . . . I think you know ’cause I was trans and he didn’t like it.Annie explained how transphobia shaped her work expe-riences and how her experience compared with cisgender sex workers:It’s different in the way you have to be careful because a lot of people wanna try [sex with a trans sex worker]. And after they’ve tried it, they get the guilt and they can’t deal with it . . . they can’t deal with their emotions. And that’s when it becomes rage.Consequently, a second theme that emerged was negotiat-ing gender expression with clients as a way to reduce potential violence.Gender Identity DiscoveryParticipants described how violent incidents occurred as a result of clients’ misreading or discovering one’s gender identity while negotiating the terms of the sex work activ-ity or during the transaction. Jasmine explained a violent incident:I got beat up in a public washroom. I got this cheekbone cracked over 10 dollars . . . We were in the cubical there and he wanted his 10 dollars back ’cause he found out I was trans. I said no. My face was like that [swollen]. I couldn’t even open my eye. Didn’t get the 10 dollars though. I jumped out of the cube and got away.Participants did not necessarily intentionally pass as cis-gender; rather clients would at times misread gender, which put participants in the position of having to dis-close their gender while negotiating the terms of the date. This disclosure, given the context of transphobia in which participants are situated, puts them at risk of potential violence. Below are two examples that detail how partici-pants feared being murdered if clients discovered their gender identity.My rule is that when a car pulls up, I tell them right away because it’s only fair for them to know. I don’t try and mask who I am. . . . I know that there’s other girls out there that do that but I think that that’s a good way to get beat up or murdered. (Bree)It’s good that way up front . . . because if they find out that you’re not a girl, and you tell them that you’re a girl, your life is at risk. They might kill you. Because there’s some guys out there that are homophobic and they don’t wanna be with a guy at all and they might just kill you once they find out so I don’t do that. I don’t play that danger anymore. (Leila)In the context of transphobia, participants feared for their safety and their lives if clients discovered their gender. As a result, some employed disclosure strategies to protect against client violence, whereas others managed potential client violence differently. Pat explained,They normally don’t [find out] and I’m pretty good at keeping myself unreadable. Also when I get into a car I basically can sense whether or not, if the possibility that I do end up getting found out happens, that I will still stay safe.In addition, some participants resisted continuously dis-closing their gender identity, such as Mindy who explained, “I don’t disclose what I am, I refuse.”Police InactionParticipants revealed that they did not report client vio-lence to police because, as Jasmine explained, “It’s use-less. Why even report it ’cause nothing’s gonna be done.” Participants felt the police would not act on their behalf if they reported violence, and this was attributed to stigma related to sex work, gender, and drug use. Thea explained,One of my trans girlfriend’s got killed . . . She got wrapped up and thrown in a dumpster. And [the police] sorta knew [the description of] the truck, but they didn’t pursue it too much. Every time a [trans person] goes they never do it too hard. Unless the guy is right there with blood dripping on his hands.Jasmine described how police responded to her being violently assaulted by a client:Took the police 22 minutes to get there. Why, because it was a transsexual prostitute. Let her get killed, who cares. . . . And I was doing this naked too. Getting dragged up and down the hall screaming for my life. Anyway the police get there and I said call the ambulance, I need an ambulance, I’m gonna have a heart attack and they said, fuck you, die junkie. . . . I was begging and begging.Police inaction reinforced participants’ feelings of deserving violence. For example, after describing a vio-lent physical assault by a client, Trace explained how 186 Qualitative Health Research 27(2)they worried about being arrested for sex work if they sought medical care:I just went home and I told my friend this is what happened and they wanted me to go see a doctor, but I was too embarrassed by the whole ordeal and I just didn’t want to. I didn’t want to get in trouble ’cause I thought I would get arrested for being on the streets prostituting myself, so I thought well I guess I was kind of asking for it.DiscussionResponding to calls for research that situates gender as central to sex workers’ lives (Bhattacharjya et al., 2015), our study explored how the social-structural contexts of transphobia and criminalization shaped trans sex work-ers’ experiences of violence. The findings illustrated that gender was intimately intertwined with the remarkable violence trans sex workers experienced. This violence impacted working conditions and interactions with cli-ents and police. In particular, the findings of transphobic violence and gender identity discovery tease out how transphobia, or cissexism (Serano, 2007), is at the core of the expectation that sex workers disclose their gender to every client. Within this social-structural context, trans individuals are perceived to violate gender norms and are subject to continual gender policing. Trans women are considered to be deceivers (not “real” women), and this is used to justify transphobic violence (Bettcher, 2007; Perry & Dyck, 2014; Schilt & Westbrook, 2009; Serano, 2007). Hence, the responsibility is placed upon trans sex workers to disclose their gender or face violence instead of responsibility being placed on clients to not be violent. Research undertaken in international settings also found trans women sex workers faced client violence related to discovery of their gender (Bhattacharjya et al., 2015; Nemoto, Operario, Keatley, & Villegas, 2004; Reisner et al., 2009; Simić & Rhodes, 2009). Thus, this study con-tributes to the literature by demonstrating how trans sex workers adapt their gender expression as a way to man-age client violence.In addition, drawing on concepts of structural and symbolic violence facilitates an understanding of why participants in our study felt it was not in their best inter-ests to report client violence to police. Symbolic violence is the process whereby the oppression of marginalized groups is regarded and enacted upon as natural and as part of this process individuals come to participate in their own subjection (Bourdieu, 2000); a process that maintains dominant relationships (e.g., relationships between police and sex workers; Bourdieu, 1994). Structural violence is embedded within social structures and refers to political and economic arrangements that result in harm (Farmer, Nizeye, Stulac, & Keshavjee, 2006). It is often concealed, like symbolic violence, due to its internalization and institutionalization (Scheper-Hughes, 1996). Structural violence, like stigma (Link & Phelan, 2001), depends upon social, economic, and polit-ical power and inequality (Galtung, 1969). Thus, drawing on the concepts of structural and symbolic violence can help elucidate how the police maintain and reinforce their dominant relationship over trans sex workers by not responding appropriately to their experiences of violence. The internalization of symbolic and structural violence is also illustrated by Trace’s above example of not reporting client violence because they felt they were “asking for it.”Police and sex work laws have historically not pro-tected trans sex workers (Ross, 2012; Sausa et al., 2007), including in our study setting where the police infamously ignored calls from the community to investigate missing women and sex workers (Oppal, 2012). This historical context contributes to trans sex workers’ reluctance to report violence or to engage with police (Namaste, 2000; Rhodes et al., 2008; Stotzer, 2009) as demonstrated in our study. Lack of police response to violence against trans sex workers is firmly rooted within the context of crimi-nalization, where sex workers are considered criminals, and within the context of transphobia, where trans per-sons are framed as deviant.Given the inclusion of two-spirit individuals in this study and the overrepresentation of Indigenous partici-pants, it must be noted that the violence experienced by participants in the study is also situated within social-structural contexts of racism, poverty, and colonialism (Hunt, 2013; Simpson, 2004). Colonialism and the ongo-ing attempts by the state to destroy Indigenous peoples and cultures, including residential schools and displace-ment of land (Truth and Reconciliation Commission of Canada, 2015), are inseparable from current health ineq-uities and discrimination experienced by many Indigenous peoples (Adelson, 2005; Bingham, Leo, Zhang, Montaner, & Shannon, 2014; Reading & Wien, 2009). In addition, many Indigenous persons in Canada continue to experi-ence barriers to economic and employment opportunities due to colonialism and systemic racism (Reading & Wien, 2009). As such, Indigenous trans sex workers may face increased levels and severity of violence due to rac-ism, economic discrimination, and gendered power inequalities which are intersecting social-structural vul-nerabilities (Bourgois, Prince, & Moss, 2004; de Vries, 2015; Meyer, 2012; Saffin, 2011).Legal and Policy ImplicationsDue to the stigmatized and criminalized character of buy-ing and selling sex in Canada and elsewhere, sex workers routinely face violence due to being conceived of as deserving of criminal punishments and violence (Shannon Lyons et al. 187et al., 2015; World Health Organization, 2005, 2012). Moreover, it is understood that criminalization increases sex workers’ vulnerability to violence and HIV infection (Bhattacharjya et al., 2015; Shannon et al., 2015). For example, sex workers who face violence are less able to engage in HIV prevention, such as condom negotiation with clients (Deering et al., 2013; Shannon et al., 2009; World Health Organization, 2005). As the findings illus-trate, Canadian sex work laws heighten trans sex work-ers’ vulnerability to client violence because they have to rush gender disclosure with clients. Indigenous trans sex workers may be more vulnerable to the harms of crimi-nalization as evidenced by the vast overrepresentation of Indigenous persons in Canadian jails and prisons (The Correctional Investigator, 2014). In contrast, the decrimi-nalization of sex work in New Zealand has improved sex workers’ working conditions and the relationships between sex workers and police (Abel, 2014). Thus, this international work and our findings support the decrimi-nalization of sex work as a necessary tool to promote trans sex worker’s occupational safety and health.It is imperative that structural interventions that address transphobia and colonialism are embedded within social structures (e.g., police) to improve the health and economic security of trans sex workers. Interventions and policies that remove barriers to economic opportunities and that support transition-related health care for those interested in transition need to be implemented and eval-uated. For example, in 2012, Argentina introduced a Gender Identity Law that recommends universal cover-age for transition-related health care and allows for changes to gender, image, or birth name on their identity card and birth certificates without psychiatric evaluation (Socías, Marshall, Arístegui, Zalazar, et al., 2014). Broader antistigma education programs and policies (e.g., gender education in schools) are vital to reduce transphobic violence, and interventions in health care set-tings are required to address the serious structural and cultural competency issues for trans populations in accessing health services (e.g., substance use treatment; Bauer et al., 2009; Lyons et al., 2015).Limitations and Future DirectionsIt is important to acknowledge the heterogeneity of trans persons and to note the study sample cannot be assumed to represent all trans and gender diverse sex workers, and pol-icy changes, such as the decriminalization of sex work, may produce different results in Canada than in other settings. Very little is known about the experiences of two-spirit sex workers; however, including two-spirit participants in this study may have served to overshadow their unique experiences, particularly concerning Indigenous ancestry. Indigenous persons are overrepresented in the local environment due to colonialism and the displacement of Indigenous peoples in Canada (Hunt, 2013). Thus, future research would benefit from two-spirit specific research conducted by Indigenous peoples and/or in accordance with Indigenous research methods and ethics. In addition, while a participatory analysis approach enriched and validated the data analysis, involving more than two research assistants in future research may help to offset any potential bias. Finally, the data used in this analysis are based on self-report and may be susceptible to response biases, which may include an underreporting of violence.ConclusionThis study offers insights into how the contexts of trans-phobia and criminalization of sex work shaped experi-ences of violence among trans sex workers by perpetuating gender-based violence and strained relationships with police. The findings illustrate that the decriminalization of sex work is necessary to improve the workplace health and safety of trans sex workers. In addition, culturally based interventions and policy reforms (Hunt, 2013; Rowan et al., 2014) tailored to the unique needs of trans sex workers are required, including those specific to vio-lence and sexual assault prevention focused on perpetra-tor interventions.AcknowledgmentsWe thank all those who contributed their time and expertise to this project, particularly participants, research assistants, com-munity advisory board members, and partner agencies. We wish to acknowledge Chrissy Taylor, Solanna Anderson, Elena Argento, Krista Butler, Peter Vann, Sarah Allan, and Jill Chettiar for their research and administrative support.Authors’ NoteA version of this article was presented at Canadian Association for HIV Research Conference, April 2013, Vancouver, British Columbia.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.FundingThe author(s) disclosed receipt of the following financial sup-port for the research, authorship, and/or publication of this arti-cle: This research was supported by operating grants from the U.S. National Institutes of Health (R01DA033147). Tara Lyons, Andrea Krüsi, and Will Small are supported by the Canadian Institutes of Health Research. Kate Shannon is supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS, and Michael Smith Foundation for Health Research.188 Qualitative Health Research 27(2)Notes1. Two-spirit is a dynamic concept that sits outside of binary understandings of sex and gender. The term was adopted in 1990 at a meeting of Indigenous peoples, and it is used to describe an Indigenous person who has feminine and masculine spirits (Fieland, Walters, & Simoni, 2007). Two-spirit is also used by some Indigenous peoples to describe their sexual orientation as lesbian, gay, bisexual, or queer (Ristock, Zoccole, & Passante, 2010).2. First Nations and Métis are two of the three officially rec-ognized Aboriginal groups in Canada (Bell, 2014). There were no participants of Inuit ancestry, the third recognized group, in our study.ReferencesAbel, G. M. (2014). A decade of decriminalization: Sex work “down under” but not underground. Criminology and Criminal Justice, 14, 580–592.Adelson, N. (2005). 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International Journal of Transgenderism, 14, 3–17.Author BiographiesTara Lyons, PhD, is a research scientist with the British Columbia Centre for Excellence in HIV/AIDS.Andrea Krüsi, PhD, is a postdoctoral fellow with the School of Population and Public Health at the University of British Columbia and the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, British Columbia, Canada.Leslie Pierre works at Providing Alternatives, Counselling & Education (PACE) Society in Vancouver, British Columbia, Canada.Thomas Kerr, PhD, is the codirector of the Urban Health Research Initiative at the British Columbia Centre for Excellence in HIV/AIDS and a professor in the Department of Medicine at the University of British Columbia in Vancouver, British Columbia, Canada.Will Small, PhD, is an assistant professor in the Faculty of Health Sciences at Simon Fraser University and a research sci-entist with the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, British Columbia, Canada.Kate Shannon, PhD, MPH, is the director of Gender and Sexual Health Initiative at the British Columbia Centre for Excellence in HIV/AIDS and Canada Research Chair in Global Sexual Health and HIV/AIDS at the University of British Columbia in Vancouver, British Columbia, Canada.

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